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General NPI Number Information
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NPI Number | 1174748354
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Entity Type | Individual
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Provider Name | KIM FONNER
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Gender | Female
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Dates
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Enumeration Date | 04/14/2007
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Last Update Date | 08/28/2017
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Provider Practice Location Address
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Address Line | 3395 W LAKE PARADISE RD
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City | MATTOON
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State | IL
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Zip | 61938-8969
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Country | US
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Telephone | 217-234-2327
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Fax |
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Provider Business Mailing Address
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Address Line | 3395 W LAKE PARADISE RD
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City | MATTOON
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State | IL
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Zip | 61938-8969
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160-002514
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 056008777
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License Number State | IL
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